Achalasi1.docx
- 文档编号:2478764
- 上传时间:2022-10-30
- 格式:DOCX
- 页数:13
- 大小:221.11KB
Achalasi1.docx
《Achalasi1.docx》由会员分享,可在线阅读,更多相关《Achalasi1.docx(13页珍藏版)》请在冰豆网上搜索。
Achalasi1
Achalasia
Achalasiaisamotordisorderusuallyaffectingtheentirelengthoftheesophagus.Althoughthecauseofachalasiaisunclear,approximately10%ofcasesoccurinchildren.Eventhoughthisdiseaseisrelativelyuncommoninchildren,itseemstobeincreasinginfrequency.Twothirdsofaffectedchildrenareboys.Whethertheconditionisbeingdiagnosedatanearlierageorthereisatrueincreaseinitsincidenceisunclear.ThisdisorderiscausedbyfailureoftheLEStorelaxandfailureoftheesophagustoadvancefoodintothestomach.
Figure1:
Chestx-rayshowsanair-fluidlevelinthemiddleofthechest(arrow)inapatientwithachalasia.
Mostchildrenwithachalasiapresentwithsymptomsofseveralmonths’toseveralyears’durationconsistingtypicallyofvomitingofundigestedfood,severebadbreath,andsignificantdysphagia(difficultyswallowing).Thesechildrenalsomayhaveprolongedcoughingspellsaftermeals.Weightlossiscommonbecausethenutritionalstatusisaffected.Childrenoftencomplainofpainbehindtheirbreastboneorburningsecondarytoesophagealirritationfromfoodthatisstuck.Usuallythereisadelayinestablishingadiagnosis.Achestx-raymayshowawideninginthemiddleofthechestandafluidlevelintheesophaguswhenthechildissittingorstanding.(Figure1A).
ThediagnosisusuallyissuspectedafteranupperGIseriesshowsnarrowingattheLESwithalargeesophagusaboveit(birdbeakdeformity)(Figure1B)
Inaddition,thereisnorelaxationoftheLESonUGIstudy.Thediagnosisisconfirmedbymanometric(pressure)evaluationrevealinganelevatedrestingpressureintheesophaguswithoutevidenceofrelaxationoftheLES(Figure2).Therealsoisabsenceofcoordinatedcontractionsintheesophagus.
Figure2:
ManometricstudyshowsamarkedlyelevatedrestingpressureintheesophaguswithoutevidenceofrelaxationattheLESinapatientwithachalasia.
Theidealtreatmentofpatientswithachalasiaiscontroversial.In1971,VanTrappintroducedtheconceptofballoondilationofthenarrowedLESforadultpatients.Balloondilationisusedinchildrenbutseemstobelesssuccessfulinrelievingsymptomsthaninadults.Theincidenceofpost-dilationGERmaybehigherinchildren,andtheprocedureistechnicallymoredifficultinyoungerpatients.OtherapproachesforreliefofsymptomsincludeinjectionofbotulinumtoxinintotheLES.Althoughthistechniquehasgainedpopularityinmorerecentyears,itseffectivenessusuallylastsonlyafewmonths.Medicalmanagementisalsonotsuccessful.Becausenon-operativetherapyisrarelysuccessful,especiallyforaprolongedperiod,mostchildrenwithachalasiarequireanoperationforlong-termrelief.
In1913,Hellerdescribedanoperationforreliefofsymptomsofachalasia.Withadvancementsinminimallyinvasivesurgery,thisprocedurehasbecomeanattractiveapproachforsurgicalmanagement.Althoughesophagomyotomy(Heller’sprocedure)hasbeenreportedusingeitherthelaparoscopic(throughtheabdomen)orthethorascopic(throughthechest)route,thelaparoscopicrouteisnowfavored.TherearemanyreportsinadultsdescribingtheeffectivenessofalaparoscopicHellermyotomyforreliefofsymptomsresultingfromachalasia,buttheexperienceinthepediatricliteratureisnotnearlyaslarge.
Themostcontroversialaspectofperformingalaparoscopicesophagomyotomyinachildiswhetherornotananti-refluxprocedureshouldbeadded.Thiscontroversyalsoexistsintheadultliterature.Mostadultsurgeonsfavortheperformanceofananti-refluxoperationbecauseitisrelativelyeasytoaccomplishandpreventstheneedforasecondprocedureifGERdevelops.Inmostchildrenafundoplicationisnotperformed.
Figure1:
Intraoperativephotographdepictsthecompletedesophagomyotomytoalengthof8cm.Themusclefibersarewidelyseparated(openarrows),andtheanteriorvagusnervecrossesthesubmucosa(solidarrow).
Figure3:
Intraoperativephotographdepictsthecompletedesophagomyotomytoalengthof8cm.Themusclefibersarewidelyseparated(openarrows),andtheanteriorvagusnervecrossesthesubmucosa(solidarrow).
Esophagomyotomy
Forthelaparoscopicesophagealmyotomy,theplacementoftheincisionsissimilartothatusedforfundoplication(Figure1).Identicalinstrumentsareemployedforalaparoscopicesophagealmyotomyasforalaparoscopicfundoplication.
Withanoperativeplanofmyotomyandanteriorfundoplication,theinitialstepistodividethebloodvesselsconnectingthestomachandspleeninordertofreetheupperstomach.Next,theanesthesiologistisaskedtointroduceanappropriate-sizeddilatorthroughthemouthandintothestomachtoopenuptheloweresophagus.Somesurgeonsalsouseesophagoscopytodothis.
Thefirststepinperformingthemyotomyiscarefulseparat
- 配套讲稿:
如PPT文件的首页显示word图标,表示该PPT已包含配套word讲稿。双击word图标可打开word文档。
- 特殊限制:
部分文档作品中含有的国旗、国徽等图片,仅作为作品整体效果示例展示,禁止商用。设计者仅对作品中独创性部分享有著作权。
- 关 键 词:
- Achalasi1
![提示](https://static.bdocx.com/images/bang_tan.gif)